How do new disorders get into the DSM?

Listening to Prozac

How do new disorders get into the DSM?

More than half the experts who compile the Diagnostic and Statistical Manual of Mental Disorders have ties to the pharmaceutical industry, according to a study published last month in the journal Psychotherapy and Psychosomatics. Produced by the American Psychiatric Association, the DSM is the guidebook used by mental-health professionals to diagnose mental illness. Fifty-six percent of its contributors have received research funding, speaking or consulting fees, or other forms of financial compensation from drug companies, the recent study reported (though the authors did not determine whether these relationships existed before, during, or after the experts worked on the manual).

The study's lead author concluded that such connections are troubling because pharmaceutical firms "have a vested interest in what mental disorders are included in the DSM." Critics of the manual have charged that some of its diagnoses, such as social anxiety disorder and generalized anxiety disorder, are pretexts for prescribing profitable drugs like Zoloft and Effexor. Their claims prompt a question: How do new ailments make it into the DSM, and who decides?

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The first edition of the DSM, which appeared in 1952, listed 128 mental disorders. In the fourth and most recent version, issued in 1994, that number had ballooned to 357. It's likely to rise again in the forthcoming DSM-V, due out in 2011. Hundreds of researchers, editors, and administrators take part in evaluating new kinds of psychopathology. If revisions proceed as they have in the past, decisions about which new conditions to admit will be made by 15 to 20 committees appointed by the APA, each concerned with a particular category of mental illness (mood disorders, for example, or anxiety disorders).

When the committees start meeting in 2007, one of their first tasks will be sorting through a stack of proposed disorders, many of them generated by a review of recent research. Others will be drawn from an appendix in the DSM-IV that lists conditions deserving "further study" and from an APA Web site called the DSM Prelude Project that is currently soliciting from the clinicians who use the manual.

To make it into the DSM-V, a new disorder will have to meet a host of criteria. Its symptoms must be severe enough to cause impairment or distress (a possible deal-breaker for one proposed diagnosis, caffeine withdrawal disorder). New diagnoses must also be sufficiently different from categories of illness already recognized by the manual. Pathological grief disorder, for example, characterized by prolonged and excessive anguish following the loss of a loved one, is a strong contender for inclusion in the DSM-V. Its supporters must conclusively show, however, that it is distinct from similar conditions, like major depression.

Advocates of a new diagnosis must also demonstrate that it won't generate false positives—people who meet the diagnostic criteria but don't actually have the condition. That could be a problem for binge eating disorder, a diagnosis that has generated significant research but might apply to a disconcertingly large proportion of America's overweight population. Disorders that are judged to be politically sensitive may also come in for added scrutiny. That was the case for masochistic or self-defeating personality disorder, a DSM-IV candidate that was scrapped when critics objected that it might be used to suggest that victims of violence invited or enjoyed being abused. Likewise, premenstrual dysphoric disorder was proposed for inclusion in DSM-III and again for DSM-IV but was relegated to the "for further study" appendix after protests from women's groups, who said that the category treated a normal biological function as a pathology. (The disorder may yet make it in, however: In 2000, the drug company Eli Lilly and Co. won FDA approval to market the antidepressant fluoxetine—better-known as Prozac—as a treatment for PMDD, which may bolster the diagnosis' chances.)

The DSM committees will review the research that has been conducted on each condition, examining the quantity and quality of supporting evidence. If there are gaps in the data available for a proposed disorder, the APA may commission its own field trials. When a new disorder is recommended by the work group, a draft version will be produced, on which the mental-health profession and the general public will be invited to comment, most likely via an APA Web site. The final decision will rest with the DSM-V Task Force, the council that will oversee the revision. Whichever diagnoses make it into the next edition of the manual, APA officials say they will be accompanied by a new feature: a list of the potential conflicts of interest of all DSM contributors.